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The Impact of Dynamic Seating on Classroom Behavior of Students with

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 ORIGINAL ARTICLE
The Impact of Dynamic Seating on Classroom Behavior of Students with Autism
Spectrum Disorder
How to Cite This Article: Matin Sadr N, Haghgoo H, Samadi S.A, Rassafiani M, Bakhshi E, Hassanabadi H. The Impact of Dynamic Seating on
Classroom Behavior of Students with Autism Spectrum Disorder. Iran J Child Neurol. Winter 2017; 17(1):29-36.

Nader MATIN SADR PhD , 1
Hojjat Allah HAGHGOO PhD 1,
Sayyed Ali SAMADI PhD 2,
Mehdi RASSAFIANI PhD 3,
Enayatollah BAKHSHI PhD 4,
Hossein Hassanabadi MD 5
1. Depatment of Occupational Therapy,
University of Social Welfare and
Rehabilitation Sciences, Tehran, Iran
2. Departmen t of Life and Helath
Science, University of Ulster, UK
3. Pediatric Neurorehabilitation
Research Center, University of Social
Welfare and Rehabilitation Sciences,
Tehran, Iran
4. Department of biostatistics,
University of Social Welfare and
Rehabilitation Sciences, Tehran, Iran
5.Department Physical Medicine and
Rehabilitation, University of Medical
Science, Mashhad, Iran
Corresponding Author:
Haghgoo H.A. PhD
University of Social Welfare and
Rehabilitation Sciences, Tehran, Iran
Tel: +98 9198647961
Email: h.haghgoo@yahoo.com
Revised: 20-Jan-2016
Last Revised: 9-May-2016
Accepted: 11-May-2016
Abstract
Objective
Children with autism have sitting and on-task behavior problems in class. In
this study, the effect of three alternative classroom-seating devices such as
regular classroom chairs, therapy balls, and air cushions were examined on
students’ classroom behavior.
Materials & Methods
15 students with autism participated in this A1-B-A2-C multiple treatments
study from Mashhad’s Tabasom School, Mashhad, Iran in 2014. Students’
behaviors were video recorded in three phases: sitting on their common chairs
during phase A, air-sit cushioned in phase B, and ball chairs in phase C. Sitting
times and on-task behaviors were quantified by momentary time sampling
and compared during different phases for important changes during 8 wk.
Additionally, the Gilliam Autism Rating Scale-Second Edition test was used
to examine stereotyped movements, social and communication skills of the
students in the before and after research.
Results
Significant increases in in-seat behaviors in 86.7% (thirteen out of 15) of the
students and on-task behaviors in 53.3% of the students (eight out of 15) when
seated on therapy balls. Air cushions had no significant effects on in-seat/on-task
behaviors. The results also showed significant decrease in stereotyped movement
and increase in communication and social skills of these students. The teachers
also preferred the use of the balls and/or air-cushioned chairs for their students.
Conclusion
Therapy ball chairs facilitated in-seat behavior and decreased autism related
behavior of the students with Autism Spectrum Disorder in class.
Keywords: Autism spectrum disorder; Students; Dynamic seating; Iran
Introduction
The overall population of Autistic Spectrum Disorder (ASDs) is 14.7 per 1000
(one in 68) in children aged 8 yr old (1). In Shiraz/Iran 1.9% of children had been
diagnosed with ASD (2). Based on the evidence reviewed, the median of prevalence
estimates of autism spectrum disorders was 62/10 000 (25). A report in 2014 in Iran
represents a prevalence rate of 95.2 per 10,000 (25). Similar findings reported in
2015 in Iran (26).
Hence, the increasing rate of ASD prevalence is a great challenge for the education

Iran J Child Neurol. WINTER 2017 Vol 11 No 1 29

 The Impact of Dynamic Seating on Classroom Behavior of Students with Autism Spectrum Disorder
system and necessitates national efforts to eliminate
consequences.
Children with ASD exhibit inattention and distractibility
more than normal children (3, 4). These children confront
various academic problems, such as difficulties in class
participation, low attention span, and inappropriate
behaviors which hinder their ability to take part in
educational activities (5). They are distracted easily
from education by their own repetitive, restless, and
disruptive classroom behaviors. These students usually
experience disappointment in educational progress with
usual intervention strategies, since these strategies do
not deal with the sensory issues that may diminish the
upsetting behavior (6, 7).
One main characteristic of children with ASD is their
problems in sensory processing and sensory integration
which negatively impact their engagement in daily
activities (8). Sensory integration deficiencies in these
children results in poor engagement in academic tasks (9).
Each child has a different model of sensory processing
insufficiency involving tactile, proprioceptive, vestibular,
visual, and auditory processing which may lead to
sensory seeking and finally affect his/her educational
achievement (10). Avoiding tactile experiences and
reduced motor responses due to hypersensitivity or
hyposensitivity to touch input needs more powerful, or
numerous tangible inputs for regulating their arousal
level (9). Everybody needs efficient sensory inputs
to organize an adaptive behavior, which would be
helpful in providing the best conditions for learning (5).
When specialists use appropriate programs to supply
children who need sensory stimulation, these children
participate actively in daily living performances because
they maintain arousal states for adapting behavior and
reacting to environmental challenges (10). Nowadays,
occupational therapists have focused on adjusting the
environment for ASD students to help them achieve
academic improvements (3).
The environmental modification in the classroom can
increase students’ engagement in academic tasks (11).
Accordingly, the relationship between the student and
the classroom environment needs to be better clarified
in order to facilitate educational performance for all
students in inclusive classrooms (3). Ecological systems
viewpoints express the risks or benefit that affect the
30
relations between the student and the environment (12).
Therefore, ignoring proper changes in environment may
have severe negative impacts on the learning processes
(3). In normal situations, students usually sit on school
chairs for 5 hours in each single school day. This fact
highlights the importance of using suitable remedy
chairs and tables in schools. Children with autism need
comfortable school chairs to gain success in educational
achievements (3). Finding appropriate chairs is possible
through investigating the impacts of different changes
in seats on academic performances of ASD students,
because providing different chair choices in class
improves their academic experiences (13).
The application of the therapy balls as an alternative
chair may provide chances for the students with sensory
integration deficiency to settle better on chairs in class
and engage in the class task (9). On the other hand,
sitting on balls as chairs has its own limitations such as
occupying a large space in class, which may hinder its
application in small classes as well as the need for carpet
under the ball. In addition, to ball sitting, air cushions
can also be used because they have some advantages,
such as being cheaper (14) or more stable compared to
therapy balls. Therefore, if air cushions have competitive
therapeutic effects, their usage in classrooms would be
better than ball sitting.
Some questions were address in this study as follows:
Which type of seating (chair, air cushion, or ball) is
preferred to be used by the teachers? To what extent will
dynamic seating chairs affect on-task/in-seat behaviors
in a special education classroom? To address these
questions, the impacts of sitting on a chair, ball, and/or air
cushion on in-seat/on-task behaviors were investigated.
Materials & Methods
Research Design
A single-case, multiple treatment A1-B-A2-C design
was used to explore the influence of three seating
options, including typical chairs, therapy balls, and air
cushions on in-seat and on-task behaviors of 15 students
with ASD. During the two A phases, all students sat on
typical chairs. Then, they sat on either cushions or balls,
each for 2 weeks. To tackle the effect of intervention
order, in phase B, eight students were seated on air
cushions and seven on balls, and during phase C, the ball
Iran J Child Neurol. WINTER 2017 Vol 11 No 1
 The Impact of Dynamic Seating on Classroom Behavior of Students with Autism Spectrum Disorder
and air cushion groups were changed with each other
(cross-over); that is, the students who sat on balls in
phase B sat on air cushions in phase C and vice versa. To
remove any novelty effects, the students were initiated to
use stability balls and air cushions instead of their chairs
for 2 days, before baseline data gathering.
Participants
In four classes, 15 participants who studied naturally
were selected with convenience sample from the
preschool students in an autism elementary school
(Tabasom) in Mashhad, Iran in 2014. All the students
took their own routine medication during the research
period. According to their teachers’ reports, most of
children were identified as having difficulty with in-
seat and on-task behavior. The inclusion criteria were
ASD students aged between 7 and 10 yr. The exclusion
criterion was any physical disability interfering with
sitting on a ball or a cushion.
Procedures
All the participants’ parents were provided with the
information sheet and ensured that their participation
in the research was voluntary, and that they were able
to withdraw from the study at any stage of the data
collection process. Following their consent, data were
collected in the participants’ convenient time and day
with ethics approval code: USWR.REC.1392.118 on
5th November 2013. All students with ASD provided
consent included in the study.
Data Collection
Video Recording
Camera recorders were set in the class and the students’
behaviors were recorded during class tasks. Assessments
were done three times per week every other day, with an
overall of 24 sessions for all classes. Each participant was
monitored for 10 min per session. Their behaviors during
class time (sitting times and on-task behavior) were
recorded by a video camera. Two intervention phases
were compared with the child’s baseline and withdrawal
phases. Two teachers were trained as spectators of video
films. In-seat and on-task behavior data were gathered via
momentary time sampling (MTS). The spectators coded
the student’s behavior at 10 sec intervals individually,
Iran J Child Neurol. WINTER 2017 Vol 11 No 1
stopped the video, and marked the interpretations on each
child in the allocated table in each session; therefore, 60
observations per session per participant resulted. These
MTS intervals were provided to make the observations
more valid and representative of the child’s behavior
throughout the baseline and interventions periods. Two
coding categorizations permitted the observers to obtain
in-seat and on-task behaviors of students. The teacher
gave no extra feedback on students’ sitting and on-task
behaviors during the research. However, if a student
had a behavior that could possibly be dangerous to him/
her, peers, or the teachers, it had to be prevented by the
teachers.
Video records were regularly checked throughout the
study by two observers to determine inter rater reliability
agreement for at least one session per phase for each
of the participants. Inter rater agreement percentages
ranged from 95% to 100% for in-seat behavior and from
85% to 100% for on-task behavior. This inter-reliability
ranged from 88% to 100% (15).
On-Task Behavior
Participation was described as “oriented towards
appropriate classroom activity or teacher and either
interacting with materials, responding to the speaker
or looking at the speaker.” (5). This definition included
writing as well.
In-Seat Behavior
Data of in-seat behavior were defined as: any of the
child’s buttocks to get-in-touch with the seat segment of
the chair and all legs of the chair to get-in-touch with
the floor (5). For the intervention phase (B), any part of
the student’s buttocks in contact with the air cushion,
the air cushion to get in touch with the seat segment of
the chair, all the legs of the chair to get-in-touch with
the floor (16). For the intervention phase (C), in-seat
behavior was defined as any segment of the student’s
buttocks to getting in touch with the ball, the ball to
getting in touch with the floor, and at least one foot to
getting in touch with the floor (5).
The researchers considered on-task and in-seat selections,
because the students might have been on-task but out
of the seat, cushion, or ball. Conversely, the students
in sitting positions might have been doing stereotyped
31
 The Impact of Dynamic Seating on Classroom Behavior of Students with Autism Spectrum Disorder

movements. Therapy balls were individually fitted for every student

Teacher Social Validity Scale
A social validity questionnaire was used at the last
part of the study to evaluate the teachers’ satisfaction
about the interventions. The questionnaire involved 10
questions and assessed the impacts of the intervention
on sitting and engagements, in addition to preference
among therapy balls, air cushions, or chairs. Questions
were answered on a 5-point Likert scale that ranged
from strongly disagree [1] to strongly agree [5].
GARS II (Gilliam Autism Rating Scale-Second
Edition)
The GARS II test was fulfilled by a trained administrator
to examine the social skills, the stereotyped movements,
and the communication of the students in baseline
and final phases for all participants. The GARS II
is a screening instrument used for the assessment
of individuals aged 3–22 yr who exhibit behavioral
characteristics that may be indicative of autism. This
is a standardized instrument, which consists of 42
items divided into three subscales that describe specific
observable and measurable behaviors (17). The items
included in this instrument are based on the definition of
autism adopted by the Autism Society of America and
on the diagnostic criteria for autistic disorder published
in DSM-IV-TR. GARS II, because it is validated and
standardized on Iranian population. In Iran, this scale’s
utility is based on Samadi, and McConkey (17).
Materials for Intervention
Therapy balls: The selected therapy balls used in the
classroom had a diameter of 45 cm (Gymnic ball, Italy).
with specific amounts of inflation that confirmed the
student could sit comfortably with his feet flat on the
floor, with knees and hips flexed at 90 degrees. Each
ball was labeled with the participant’s code. A bicycle
tire was put under the therapy ball to provide stability
and to prevent the ball from rolling too much. The inner
diameter, outer diameter, and the circumference of the
bicycle tire were 29.5, 41, and 129 cm respectively. It
limited the sway distance of the ball to less than 2 cm.
Air cushion: The Disc ‘O’ Sit cushion is round and filled
with air. It is strong enough to sit on and is designed to
fit on a classroom chair and provide movement while
seated (16).
Chair: A common wooden, iron frame classroom chair
without armrests (height, 72; depth, 34; width, 39; seat
height, 36 cm).
Then the paired t-test with SPSS ver. 19 (Chicago, IL,
USA) was used to analyze data. Normality of the data
was approved by using Kolmogorov-Smirnov. Because
of the repeated measurements method, the parametric
test of Generalized Linear Model was used to decide on
the significant differences between the interventions and
baselines.
Results
Demographic Data
The sample included 15 participants. The ages of
the participants ranged from 79 to 117 months with a
mean age of 104.27 months ± 11.98. The participants
were divided into four classes. Characteristic data
included: (10 Males 66.7%, Females 5 33.3%), age
104.27±11.98 (months), Height 129.40±10.25 (cm),
Weight 29.2±10.03 (kg).

Table 1. The Effects of Different Seating on In-Seat Behavior

Mean*
Type of chair S1 S2 S3 S4 S5 S6 S7 S8 S9 S10 S11 S12 S13 S14 S15
Chair1 44.1 34.7 54.5 54.2 26 19 41.5 44.7 47.5 44.7 51.5 41.2 45.5 14.6 45.8
Cushion 35.4 22.2 58.5 53.2 19.2 46.3 40.3 51.2 52.5 51.2 43.8 38 58.6 45.6 57
Chair2 40.5 44.5 57.2 54 22.8 41.6 17.6 46.4 56 46.4 51.2 46.8 56 36.8 59.2
Ball 58.8 51 57.6 59.7 40 59.2 50.7 58.1 58.3 58.1 48.5 44.1 45 40.6 56.6
*:= (mean of 60 times observation per session, for six sessions during 2 wk
S= Student

32 Iran J Child Neurol. WINTER 2017 Vol 11 No 1

 The Impact of Dynamic Seating on Classroom Behavior of Students with Autism Spectrum Disorder

Positive changes in in-seat behavior were significant
between A1 and C phases. Most participants (13 out
of 15) demonstrated improvements in in-seat behavior
when seated on a ball and these improvements were
from 2.9 times in S12 to 40.2 in S6, with an average
of 14.6. A2 and C Phases had an obvious difference in
11 students from 0.4 to 33.1 in S3 and S7 respectively,
with an average of 11.6. The students’ in-seat behavior
improved for S3, S6, S8, S9, S10, S13, S14, and S15
from 4 in S3 to 31 in S14, during the B phase (cushion).
In comparison with A1 phase, most students’ in-seat
behavior improved during the B phase.

Table 2. Effects of Dynamic Seating on On-Task Behavior

Mean*
Type of chair S1 S2 S3 S4 S5 S6 S7 S8 S9 S10 S11 S12 S13 S14 S15
Chair1 21.4 24 34.8 31 24.7 16 40.1 18.5 30.7 7.7 10 38.2 41.5 45.4 29.6
Cushion 7.6 15 18.7 18.8 22.7 26.5 37.6 41.3 26 6.6 7.3 21.7 29.4 45.5 18.6
Chair2 14.5 29 44 24.8 22.2 11.2 26.2 34 28.6 7.6 12.2 28.6 42 39.8 26.8
Ball 20.6 33 25.6 28.2 22.7 28.7 50 34 35 1.3 5.5 17.6 25.3 32.3 40

*:= (mean of 60 times observation per session, for six sessions during 2 wk
S= Student

The students’ on-task behavior improved only for S6, S8, and S14 students, with 10.5, 23, and 0.1 times during the B
phase (cushion) respectively in comparison with A1 phase. All other 12 students’ on-task behavior decreased from 1 to
22.8 times during the B phase. The S1/ S2/ S4/ S5/ S6/ S7/ S9/S15 students’ on-task behaviors improved from 5 in S5 to
23.8 times in S7 during the therapy ball phase (C) in comparison with A2 phase. Therefore, employing air cushion led
to an increased on-task behavior in few students and the ball in more than half of them in this study.

Table 3. Distribution of on-Task/in-Seat Behavior (per Second) and GARS II

of Participants in Different Phases (n=15)

Assessment fields
(Mean ±SD)
Type of chair In-Seat behavior On-Task behavior GARS II
Chair1 A1 40.1 ±19.6 27.8±16.2 43.4 ± 11.66
Cushion B 47.3±15 21.2±16.1 …..
Chair2 A2 43.6±17.7 25.4±16.5 …..
Ball (C) 51.2 ±13.6 26.1±17.5 39.5 ± 10.07

Table 4. P-value of in-Seat/on-Task Behavior of Participants in Different Phases (n=15)

In-seat behavior On-task Behavior

A1-B P= 0.82 A1-B P< 0.058
A1- A2 P= 0.19 A1- A2 P= 0.77
A1- C P< 0.001 A1- C P= 0.44
A2-C P< 0.001 A2-C P= 0.32

Iran J Child Neurol. WINTER 2017 Vol 11 No 1 33

 The Impact of Dynamic Seating on Classroom Behavior of Students with Autism Spectrum Disorder
As Tables 3 and 4 illustrate, the mean of in-seat behavior
scores increased significantly from phase A1 with a
Mean of 40±19.6 to a Mean of 51.2±13.6 in phase C.
These results show noticeable improvements in in-
seat behavior during the utilization of therapy balls for
classroom seating (P<0.001). Additionally, a significant
difference in sitting behavior was found in the change
between the A2 and C phases (P< 0.001). The change in
the mean scores increased significantly from a Mean of
43.6±17.7 to a Mean of 51.2±13.6 (Table 4).
Although, the mean of sitting increased from 40.1±19.6
in phase A1 to 47.3±15 in B phase, the air cushion did
statistically not differ significantly from A1 phase in in-
seat behavior when comparing A1 with B phase. Despite
improvements, on-task behaviors in most of the students
(eight students) when sitting on balls in comparison with
A2, dynamic seating had no significant positive effect on
on-task behavior.
The teachers preferred the use of balls and air cushions
for students in class, according to the social validity
questionnaire. The level of significance of the GARS II
test was positive with (P= 0.017) and a Mean of 43.4
± 11.7 in the beginning of the study, diminishing to a
Mean of 39.5 ± 10.07 at the end of intervention.
Discussion
The aim of this study was to compare the effectiveness
of dynamic seating devices on improving a students’
in-seat and on-task behaviors and decreasing autism
related behaviors within the classroom setting. Are
there any differences between sittings on dynamic or
ordinary chairs?
In-seat behavior increased significantly when the
students sat on therapeutic balls (phase C) when
compared with sitting on normal chairs. This study
proposes that ball seating in the classroom causes
an increase of 86.7% in in-seat behaviors of ASD
students with a P-value of less than 0.001. Therapy
balls provide sitting and moving concurrently, which
may satisfy sensory needs (18). In accordance with
findings by Schilling et al, significant changes in in-
seat behaviors in Attention Deficiency Hyperactivity
Disorder and ASD children have been reported when
sitting on therapy balls (5, 19). Children with autism
are supposed to select self-stimulatory behaviors, such
34
as stereotyped movements to normalize arousal levels
(14). As a result of normalizing arousal levels and
regulating sensory inputs with rocking and bouncing
on a ball, students with autism could be satisfied
physiologically and would not need to engage in self-
stimulatory behaviors (20). An agitated child may be
relaxed by gently rocking on a ball (19). Therefore,
stereotyped behaviors of the students with ASD
might be decreased with Ayres’s sensory integration
programs (21).
Sitting on a cushioned chair had no significant effect
on in-seat behavior, although it improved sitting times
for most of the students. Sitting on the ball produced
dynamic sitting that stimulated proprioceptive and
vestibular systems (18). Vestibular and proprioceptive
stimulation in ASD students who use dynamic seating
can adjust arousal situations (3, 6). Unlike the ball, a
cushion provides a more stable surface for sitting, and
the children do not need more muscle activity to keep
balance on seats. Therefore, they are less conscious
about their balance, which may diminish their arousal
level to sit calm and stay relaxed on a cushioned chair.
Ball sitting was effective for most students in this
research in the field of sitting times, but the results
demonstrated unique responses of the students with
ASD to the use of balls and cushions for sitting in the
field of on-task behavior. Most ASD students (eight out
of 15), showed a positive increase in on-task behavior
while being seated on a ball, and this increase occurred
only for a few students while using a cushion. Each
type of furniture provides different effects depending
on personal sensory needs of the students. Therefore,
maintaining an optimal arousal state of each student
depends on the type of furniture (3). Cushions provide a
more stable seat; therefore, they cannot provide enough
sensory stimulation to create functional benefits such
as increasing on-task behaviors.
Furthermore, the teachers’ reports supported the
use of balls and air cushions for the students in
class. Accordingly, the students were calmer when
compared to the use of common chairs. Since agitation
and attention deficiency seem to be due to sensory
integration impairment, sitting modification in class
condition may be beneficiary to students with autism
(19). Children with attention problems are usually
Iran J Child Neurol. WINTER 2017 Vol 11 No 1
 The Impact of Dynamic Seating on Classroom Behavior of Students with Autism Spectrum Disorder
in low arousal condition; therefore, occupational
therapists use a suitable intervention such as the “Disc
‘O’ Sit” cushion for the most favorable attention and
education (16).
Therapy balls and cushions can decrease behaviors
related to autism of the students with an ASD
significantly, according to the GARS II tests. The
students feel better and more comfortable while sitting
on therapy balls (22). Sensory processing may result
in a decrease in social isolation and inattention to
class tasks (23). Ball sitting also allows children to
release their energy and receive sensory stimulation
simultaneously. Thus, they do not need disrupting
sensory seeking behaviors (24).
When attempting to establish inclusive education
classes for ASD children, changes to the schools’
environment to provide ideal interventions for these
students are needed. The findings of this study show
that different kinds of furniture have different results
on ASD students. Understanding the priorities of
the students and the availability of different chair
choices might help in achieving more positive results,
especially in the field of on-task behavior. Ball seating
devices were found appropriate for most of the students
to increase sitting times, but the results demonstrated
unique responses of the ASD students to the use of
cushions for sitting. Use of balls for sitting appeared
to be positive in helping teachers in class to control
destructive behaviors. The teachers reported that
therapy balls and air cushions prevented disruption of
class conditions, and their use also made students more
socialized. They suggested that other teachers should
apply these interventions for ASD students as well. The
GARS II scores also approved a reduction of behaviors
related to autism in students with an ASD in this study.
As a limitation of this study, the duration of the
treatment in this study was short (9 wk), and monitoring
only four classrooms for the purpose of this research
could be considered as another limitation. A bigger
sample size and longer duration of time could possibly
strengthen the results. Working as an interdisciplinary
team is another necessary concern in inclusive schools.
In conclusion, the comparative researches help to
recognize different aspects of features of alternative
seating devices that are more suitable for specific
Iran J Child Neurol. WINTER 2017 Vol 11 No 1
sensory needs of the ASD children. With regards to
thousands of students with special difficulty in sitting
and classroom performance, these devices may be an
optional selection for solving class behavior problems.
Acknowledgement
We appreciate the cooperation of the students, their
families, co-workers, teachers, school administrators,
and staffs, with whose help this research has been made
possible.
Author’s Contribution
Dr Matin Sadr N. has contributed for study concept,
conducting research project, development of original
idea, writing the manuscript, collecting data and
statistical analysis.
Dr Haghgoo HA. and Dr Samadi SA.: Study concept,
help in writing of manuscript, development of original
idea, edition of manuscript.
Dr Bakhshi E. & Dr Rassafiani M.: Statistical analysis
and edition of manuscript.
Dr Hassanabadi H. helps in writing of manuscript. All
authors agreed to be accountable for all aspects of the
study including the integrity and content.
All authors agreed to be accountable for all aspects of the
work in ensuring that questions related to the accuracy
or integrity of any part of the work are appropriately
investigated and resolved.
Conflict of Interest
The authors declare that there is no conflict of interest.
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Iran J Child Neurol. WINTER 2017 Vol 11 No 1